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j,; =FOR OFFICE USE: --------------------------------------------------- -------------------------- ------------ ------------ APPLICATION FOR SANITATION PERMIT Permit No. ----------------------- ------- - ------------- ------- I (Complete in Duplicate) AS43 - ------------------------------------------ ------- This Permit Expires I Year From Date Issued -Date Jssued Application is hereby made to the SanDistrict —— . V. t, Local Health Dipf rict for a pqf5i &'ronsfruct and install the work herein described. T oun y nEe This application is made in.-coMP66-rice A11K C-7 t_'CFFd_1F'a K—oS49.' 0 07. JOB ADDRESS AND LOCATION- - -------51 —------- OwnerW------49F------7 ''s Name------- Fom-------- ------------------ ------ - -------------------------------------- Phone------------------------ Address-------------1?-T-F— ---------------- -------- --------------------------------------- ........----------------- Contractor's Name-----:.___0_WAfV ------------- ......................... -I 1�1 ---------,-------------------- -------------------------------------------- Phone_-------------- AA : I I , - - ------------- Insfallation will serve: Residence 2�--Apartment House,-,E] Commercial E] Trailer Court L] Motel 0 Other ❑ Number of living units: __----__ Number of bedrooms_ —Number of baths _/--- Lot size ,---./ Water Supply: Public system n syst Community m ❑ Private eDepth to Water Table -,g__ ff. T Character of soil to a depth of 3 fee+:, Sand �Gravel'M# Sa Y Loam E] Clay Loam F] Clay 0 Adobe [I Hardpan El Previous Application Made: (If yes,date-__-__-.-- ------ No N w Construction Yes � El PHA/VA: Yes E] No TYPE!OF-INST-ALL-ATI'ON';�WD-S7PECIFICA-T-IONIS-:- ' - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T.6h k: Distance from,nearesf.well---.5 Dista W PI f, c from found a ion----W----7 feri'l -�p-VVVPJr------No. of compartments.-_ ---------- ...S ize--V; 31F i k (10-A-Y Liquid depth___ '_-.........Capacity-----49 ---I Disposal Field: Distance .from nearest weil...%.6- ___-Pistance from foundation___.-J -------Ditfance to nearest lot i Number of lines_____� fix ----------------------Wngfk of each line------APP.............Width of trench---._- ___-__-_3,6 #4 t It ----- ---Total length-------------lip ----------------- Type of filter of filter material------ C!"I -. v Seepage Plt. 4,cDistance to nearest well___-----------------]Dist ln'ce from foundation----_-_---------_--Distance to nearest lot line-_-----------.--.❑ of pjfS...............7 Lining ft'�a-f6rial-------------------- -Size: Diameter---------- ------------Depth------------------------- ------ Cesspool: Distance from nearest well------- -------�_IbPlkfance from foundation-_____--- -- --.Lining material------------------------- 0 Size. Diameter--. ........... -----------------------Liquid.Capacity----------------------------gals Privy:- Distance from near'est well--------------IT Distance to nearest lot line-___--.----- -------------------------------^#___--____________________Distance.from nearest building__------__-__-__________--____-___----_ ❑ -------------------------------- ---------------------------------------------------------- At" Remodeling and/or repairing (clescril5b)-------------- ----------------- ------------------------•------- f ---------------------- ---------------------------------------------:---------- ---------------------------------------------------------------1. 1 -------------------------------- --------------------A--------------------------------------- --------------------- ---------- ------ --------------------------------------------------- ---------- --------------_------------------------------------------w----------- ---- -------------------------- ---------------------------i---------------------------------------------- -- -------------------------- ------------------------ ----- - -- --- ----- ------ - ---------- I hereby certify that I have prepared this application and that the work will be done in accordance'-w'ifh--San--J-oaquin---Count y- ordinances Staf laws, and rules and lregulafions of the San Joaquin Local Health District. O [Signe -------------- ......... ------ ----- ----- ------t---------------------------------------i----------------------------------------(Owner and/or Contractor) . =— - - - BY:------------------------------------------------------------------------------------------------------:---------------77777�� (Plot plan, showing size' of lot, location-of system in relation to wells', buildings, etc., can be placed on 7 reverse--side). ---- --------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- --- -------------------- ---------------------------------------- DATE--------0 REVIEWED BY--------- - I __I__ ---- -- ----------------- -------:---------------------------------------------- DATE-- ------------------------------f-------------------------------- ---------------- -------- BUILDING PERMIT ISSUED---------- -------------------------------------------------------------:--------- -------------------- DATE------- Alf efif-I 0=ns' ati;ns ----------------- ---------------------------------------------------------------------------------------- --------------- ---------- --------------------e_... ------- 72-C-F-7.....�A440PAA N_'S Al ----1A(!5P _RE .. 7 _ --------- ---------- --D------r W1_r_H0_wh7- --- - - IV 4 ---- - O- N-- -- {blur -------5v` - ©rte--- - ------------------ - ---- -------- ------------ ar -- --------------------------------------------------------------------------------------------- 44MAL INSPECTION - - ------- Date... ............ --------------------------- 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 1 300 West Oak Street 124 Syca-rihore Street 205 West 9th Street Stockton,California Lodi,California Monleca,,Cajifornia Tracy, California ES 9 REVISED 91-59 3M 3"63 F.P.120. ;5s,qq